What Needs to Be Done to End the Opioid Epidemic?

The opioid epidemic that started in the late 1990s has taken a staggering toll. We have lost more people to drug overdoses than in all the wars since the beginning of the past century. Sadly, although the overdose deaths have come down, we are nowhere close to declaring the end of the opioid epidemic, as was the case in the 1980s. Looking back at the successes of the past can help us understand why we’ve in many ways failed this time around.

The heroin epidemic of the 1960/70s was largely driven by U.S. soldiers who became addicted to heroin in Vietnam, as well as large quantities of heroin coming into the U.S. Socially driven epidemics end or are contained by cutting off supplies and demand. This worked very well in the 1970s.

On the supply side, the inward flux of heroin was stopped by shutting down the heroin labs. On the demand side, restrictions were placed on the prescribing of opioids.

Perhaps the boldest move was establishing methadone clinics to help the thousands of patients addicted to heroin receive methadone. This plan to curb demand and supply worked so well, many experts believed the heroin epidemic had effectively ended by the mid-1980s.

The Epidemic Ended, But Research Continued

The research into safer and more effective opioids continued, resulting in the development of an entirely new class of opioids called opioid antagonists. Naloxone, better known by the brand name Narcan, approved in 1971, was revolutionary. If given in time, naloxone reversed the effects of every known opioid, from heroin to fentanyl. Moreover, naloxone had no opioid-like properties and therefore had zero abuse potential and no street value.

The discovery of naloxone led to the development of analogs, not just to reverse an opioid overdose but to prevent relapse to opioid use in patients who have been successfully detoxed and returning home to a cue-rich environment. Ultimately, this led to the development of naltrexone, the first orally effective opioid antagonist.

If naloxone reversed the effects of every known opioid, naltrexone prevented every known opioid from binding with the opiate receptor in the body. One researcher boldly stated: “The major side effect of naltrexone is the prolongation of life.” Naltrexone was approved in 1984 for the prevention of opioid relapse.

For the first time in history, clinicians had two powerful tools at their disposal: a drug to reverse opioid overdoses and a drug to prevent opioid relapses.

How a Supply Catastrophe Rekindled an Epidemic

The opioid epidemic that lay dormant for almost 15 years was rekindled in the late 1990s by the irresponsible promotion of powerful opioids to treat chronic pain. Few in the medical community were prepared to deal with the abuse and diversion of prescription opioids, resulting in addiction, overdoses, and deaths. Access to methadone was restricted by the rigid requirements of daily visits to the clinic.

Buprenorphine, an effective opioid with a high degree of efficacy and safety, was approved with considerable restrictions that have finally been removed only in the last few years. Naloxone and naltrexone remained underutilized for a long time.

Few realized the devastating ramifications of a supply-driven opioid epidemic, and we had no experience in dealing with one. We tried to curb the demand by placing restrictions on the prescribing of opioids. This led to a huge flow of heroin, primarily from Mexico. The supply increased and prices dropped—the recipe to exacerbate the epidemic. We saw overdose deaths climb.

Narcan and Naltrexone

Something had to be done to stem the alarming increases in overdose deaths. Increasing access to naloxone made complete sense, yet it took many years for states to make this life-saving drug accessible.

It was not until 2017 that all 50 states passed laws to make naloxone accessible under a state-wide prescription. It took another six years for the FDA to grant the naloxone nasal spray over-the-counter status.

There were unfounded fears that naloxone would encourage more drug use or other issues. None of these came to pass, and today, naloxone is credited with saving thousands of lives and giving these patients a fighting chance.

We need to be aware of the major pharmacological limitations of naloxone. Naloxone can only be used after an overdose and only by a person other than the patient. The effects last for a relatively short time, 45-60 minutes.

Needle Exchanges and Harm Reduction

Harm reduction is another strategy to keep patients alive in the hope of getting them into treatment. The strategy is distributing clean syringes, test strips for drugs like fentanyl, and naloxone kits, as well as education focused on safe drug use and deploying naloxone. This approach cannot be deployed extensively as a public health measure, especially for patients in recovery and high-risk patients. It has generated a fair degree of controversy as well.

Still, there is much we can learn from the success in deploying naloxone. Naloxone is now offered at pharmacies, police and fire stations, public libraries, and free naloxone vending machines strategically placed.

If naloxone is the first broad-spectrum opioid reversal agent, naltrexone is the first broad-spectrum anti-opioid drug that will prevent every known opioid from binding with the opiate receptor. Naltrexone overcomes the pharmacological limitations of naloxone. The patient takes a pill of naltrexone to protect against ingesting opioids. It is common for street drugs like methamphetamine, cocaine, and benzodiazepines to be laced or contaminated with drugs like fentanyl.

Naloxone Reverses, Naltrexone Prevents

Just like naloxone, naltrexone is not an opioid and therefore cannot be abused; there is no risk of overdose or diversion, and it has no street value. Naltrexone elegantly takes harm reduction to harm avoidance. Moreover, it is easy to administer and fairly inexpensive, $1 for a 50mg pill. We believe that increased access to naltrexone is one of the most powerful and cost-effective public health preventative measures to deal with the supply side opioid epidemic.

Pre-exposure prophylaxis (PrEP) is a well-established strategy to prevent HIV infections in high-risk patients. In the early years, there was considerable skepticism about this measure; now, it’s the standard of care.

Who would be appropriate for naltrexone PrEP? People who might have used opioids for a short time and stopped, but feel at risk of using again. Others may want to resist peer pressure to use opioids at school or with friends. Medical students, nurses, pharmacists, other healthcare workers who want protection, peer support specialists, and others working in drug treatment programs are good candidates.

And naltrexone has another benefit: It is FDA-approved for alcohol addiction and helps patients cut down on drinking or maintain sobriety.

Final Thoughts

Much education is required going forward. Community pharmacists will also play a critical role. Since naltrexone is non-scheduled with no potential for abuse or diversion, pharmacists would eagerly welcome the opportunity to get involved in this program.

We lost over a million people to drug overdoses in the last 20 years, and we waited decades to deploy naloxone. We can turn the tide by creatively and intelligently deploying naltrexone, a medication sitting on the shelf for over 40 years, whose major side effect is the prolongation of life.

This post was co-written by Percy Menzies, M. Pharm., president of the Assisted Recovery Centers of America, a clinic based in St Louis, Missouri.